Healthcare Provider Details

I. General information

NPI: 1699515759
Provider Name (Legal Business Name): JACK PATRICK DOOLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2596 S BAY SHORE DR
SISTER BAY WI
54234-9157
US

IV. Provider business mailing address

845 N 8TH AVE UNIT 4
STURGEON BAY WI
54235-1130
US

V. Phone/Fax

Practice location:
  • Phone: 920-854-6556
  • Fax:
Mailing address:
  • Phone: 920-321-6409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6001516-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: